Time to tackle healthcare fraud

Many in Zimbabwe rely on medical aid to pay for needed healthcare, yet t he medical aid societies are faced with ever-growing losses arising from those who steal from the system through fraud.

Those who lend their cards to relatives, or pretend that care needed for relatives and friends is actually for them, are only part of the problem and have been pushed back by the complex rules the societies have introduced for prior approval for many procedures and the identity cards, with photographs, that have been introduced.

There are those in the healthcare industry, who also either commit blatant fraud or who pad bills with unnecessary tests and extra visits, and it is here that fraud is so difficult to detect.

A doctor who claims fees from a society for a consultation that never took place is perhaps rarer than the doctor who makes a patient have an unnecessary consul- tation. It could be as simple as asking a patient to make an appointment simply to be told that test results revealed no problem, something that could be said in a phone call or even a text message.

Then there are those who send a patient to a particular clinic for tests, some of which are not necessary. It is difficult for a medical aid society to argue whether a consultation or a test is required or is not required.

Interfering in the relationship between a doctor and a patient is difficult and generally considered unethical.

And then there is the possibility of collusion. A dishonest doctor or pharmacist, coupled with a dishonest patient can cre- ate payments for no service or unneeded service with the society award split.

But now that the medical aid societies have done so much to reduce blatant fraud, by the identity cards, by requiring patients to sign forms with signatures registered with the society involved, by insisting on refunds for generic drugs only, the more complex frauds involving collusion or the potential fraud of unnecessary services charged for have to be tackled.

At the fraud indaba held by the Association of Healthcare Funders of Zimbabwe (AHFOZ) last week, several new approaches were discussed.

First was the obvious need for societies to share data.

A doctor cheating with two patients from each society might not be caught by any unless they can start to see patterns and cheating with 20 patients from 10 societies. Sharing of data allows enough statistics to reveal areas where more investigation might well be fruitful.

Secondly, the societies want better law that specifically addresses healthcare fraud.

Other countries have this and it should be possible for Zimbabwe to adopt best practices and proven legal provisions.

We agree that it might well be difficult considering the confidential nature of medical relationships, but it is possible to depersonalise data, at least from the patient level and it should be possible to have competent medical advice given to the industry as a whole as to what constitutes proper treatment for a wide variety of cases and to have this advice available for the once- off treatments that may ring up suspicions.